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Toxicity Related to Chloroquine Treatment of Resistant Vivax Malaria

Professor of Medicine, School of Medicine and Pharmacology, Fremantle Hospital, Fremantle, Western Australia, Australia

David A Syed, MB BS

General Practitioner, Westport Medical Center, Fremantle

Kenneth F Ilett, PhD

Associate Professor of Pharmacology, School of Medicine and Pharmacology, University of Western Australia, QEII Medical Center, Nedlands, Western Australia; Clinical Pharmacology and Toxicology Laboratory, The Western Australian Center for Pathology & Medical Research, Nedlands

P Hugh R Barrett, PhD

Associate Professor of Medicine, School of Medicine and Pharmacology, Royal Perth Hospital, Perth, Western Australia; Western Australian Institute for Medical Research, Perth

Reprints: Timothy ME Davis FRACP, School of Medicine and Pharmacology, Fremantle Hospital, PO Box 480, Fremantle, Western Australia 6959, Australia, FAX 618/9431 2977, E-mail tdavis{at}cyllene.uwa.edu.au

OBJECTIVE: To report a case of severe chloroquine toxicity in the presence of high-grade chloroquine-resistant Plasmodium vivax.

CASE SUMMARY: A febrile 36-year-old seaman from Mumbai (Bombay) was prescribed >5 times the usual dose of chloroquine for malaria diagnosed empirically onboard ship. His fever resolved, but he developed symptoms consistent with those of chloroquine toxicity. Fever recurred 30 days after his initial presentation, and blood smear–positive vivax malaria was diagnosed. A serum chloroquine concentration at this time (91 µg/L) was above that considered effective for chloroquine-sensitive P. vivax (>15 µg/L). The patient responded to atovaquone plus proguanil followed by primaquine.

DISCUSSION: The patient was given chloroquine by his captain in a dosage regimen appropriate for quinine (2 tablets 3 times daily for 7 d). Pharmacokinetic modeling suggested that the patient's initial over-treatment was as reported and that the predicted maximum serum concentration of chloroquine (902 µg/L) was within the range seen in fatal chloroquine overdose.

CONCLUSIONS: Chloroquine-resistant vivax malaria is increasingly widespread, and transmission can occur within large tropical population centers. For drugs with a narrow therapeutic index such as chloroquine, recommended dosing regimens should be respected, and adequate information sources must be available where such drugs are dispensed by untrained personnel.

Key Words: choroquine, overdose, vivax malaria

Published Online, February 20, 2003. www.theannals.com, DOI 10.1345/aph.1C311

This article has been cited by other articles:

				J. K. Baird Chloroquine Resistance in Plasmodium vivax Antimicrob. Agents Chemother., November 1, 2004; 48(11): 4075 - 4083. [Full Text] [PDF]